Provider Demographics
NPI:1174534879
Name:SMALLEY, SCOTT EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:EDWARD
Last Name:SMALLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:83 THE PLAZA
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1365
Practice Address - Country:US
Practice Address - Phone:636-462-3958
Practice Address - Fax:636-462-3957
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019135152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317177806Medicaid
11505611OtherCAQH PROVIDER ID
MO1174534879Medicaid
MO5403130001Medicare NSC
MOV06344Medicare UPIN
MO258724545Medicare PIN
MO1174534879Medicaid
MOMA3216004Medicare PIN